So needle biopsy
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So needle biopsy. At that point, if you are looking at a squamous cell or something that looks like epithelial, then they probably need some form of directed scope. Whether it’s a panendoscopy, which applies a rigid bronchoscopy, esophagoscopy and direct laryngoscopy, or whether you go just to direct laryngoscopy – which we do more and more – depending again on the physical exam. Whether you do biopsies or not, this is kind of becoming. I think most people do not do random or blind or guided biopsies unless you have a real high suspicion. So if we are faced with this patient, that we’ve got a fine needle they say is malignant, they’ve got a unilateral lymph node, what do we do with them? We take them to the operating room and we do a direct laryngoscopy. If we find something at the base of the tongue, hypopharynx, we biopsy it and we are done. We wake the patient up and then we need to have a discussion about what are your options, how can you be treated etc. Of course, this all has to be done ahead of time. If you don’t find anything then we proceed with an open neck biopsy and I draw out an incision for a neck dissection and then make that biopsy along the lines of my incision, make a small incision. If it’s epidermoid, if it’s a squamous cell carcinoma, then you are dealing with: you’ve done your direct laryngoscopy, you’ve looked at all the other sites, you’ve got your chest x-ray ahead of time and you’ve ruled those common things, then I go ahead and do a neck dissection on that patient. There’s no point in waking them up, giving them a second anesthetic, talking to them and bringing them back for a neck dissection because that’s what they are going to need. Then they are going to need radiation for an unknown primary. So we prepare our patients and do a neck dissection right at the time of the open biopsy. Get a frozen on it and proceed. If it’s lymphoma, then of course that’s not a surgical disease. You’ve got your tissue for stains and you close and wake the patient up.
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If it’s adenocarcinoma, then we never know what to do and we always hate them because if you’ve gotten your GI workup, your mammogram, all of those things ahead of time, then do you do a neck dissection assuming it’s an unknown primary salivary gland? You know, I usually do some form of modified neck dissection but I certainly wouldn’t fault anybody that just closed because it’s hard to know what to do at that point. Of course, if it’s inflammation granuloma then you press on. If they say it’s a lot of granuloma and infection and don’t see any specific organisms, you have them look for TB and those kinds of things. Sometimes you have to remove all those lymph nodes. Atypical TB, that’s still the treatment of choice in the patient who has had a chest x-ray that’s clear, that’s got only disease in the neck. And we’ll see one, maybe two of these a year and we conservatively remove those nodes. There are some better drugs for them now and they are being used more and more, but I think the more you get the disease out – if you are doing a very conservative modified neck where you are not doing anything too radical – that’s probably reasonable.
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CT and MRI should only be done when it’s going to change the management of that disease. So you really should know before you get the scan, exactly what you are dealing with. This is an oral cavity primary with a lymph node. I don’t need a CT. It’s money that’s wasted. Because I’m not going to do anything any different just based on the CT. If it’s a Larynx cancer then that’s different. I need a CT ahead of time because whether they have cartilage invasion or not is going to partially direct how we treat the patient. But I always say, only if it is going to change how you are going to manage that patient.